NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:
Correct Answer: D
Rationale: Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.
Question 2 of 5
The client is admitted with a diagnosis of septic shock. Which intervention is the priority?
Correct Answer: A
Rationale: In septic shock, administering IV antibiotics within the first hour is the priority to target the infection causing shock. Vasopressors, catheterization, and cultures are secondary.
Question 3 of 5
Painless vaginal bleeding in the last trimester may be caused by:
Correct Answer: C
Rationale: Placenta previa causes painless vaginal bleeding due to the low-lying placenta separating from the uterine wall.
Question 4 of 5
The nurse is caring for a client with a history of a mastectomy who is receiving Tamoxifen (Nolvadex). The nurse should teach the client to:
Correct Answer: A
Rationale: Tamoxifen increases the risk of endometrial cancer, so vaginal bleeding must be reported immediately. Sun exposure, caffeine, and fluid intake are not primary concerns.
Question 5 of 5
The nurse is caring for a client with a history of Ménière’s disease. The nurse should expect the client to have:
Correct Answer: A
Rationale: Ménière’s disease affects the inner ear, causing vertigo, tinnitus, and hearing loss due to fluid imbalance.